To conduct an environmental scan of a rural primary care clinic to assess the feasibility of implementing an e-communications system between patients and clinic staff.

Increasing demands on healthcare require greater efficiencies in communications and services, particularly in rural areas. E-communications may improve clinic efficiency and delivery of healthcare but raises concerns about patient privacy and data security.

We conducted an environmental scan at one family health team clinic, a high-volume interdisciplinary primary care practice in rural southwestern Ontario, Canada, to determine the feasibility of implementing an e-communications system between its patients and staff. A total of 28 qualitative interviews were conducted (with six physicians, four phone nurses, four physicians’ nurses, five receptionists, one business office attendant, five patients, and three pharmacists who provide care to the clinic’s patients) along with quantitative surveys of 131 clinic patients.

Patients reported using the internet regularly for multiple purposes. Patients indicated they would use email to communicate with their family doctor for prescription refills (65% of respondents), appointment booking (63%), obtaining lab results (60%), and education (50%). Clinic staff expressed concerns about patient confidentiality and data security, the timeliness, complexity and responsibility of responses, and increased workload.

Clinic staff members are willing to use an e-communications system but clear guidelines are needed for successful adoption and to maintain privacy of patient health data. E-communications might improve access to and quality of care in rural primary care practices.

To measure the knowledge, perceptions, and practices of Jordanian primary healthcare practitioners (PHCPs) (physicians, nurses, midwives, and nurse aids) employed in Jordanian Ministry of Health (MoH) primary health clinics with respect to counseling on cancer (cancer screening, the signs and symptoms of cancer, and referral for specialized care).

Integration of oncology services within primary care is a means of enhancing cancer early detection, and requires involvement of skilled. In the Middle East, little is known about PHCPs’ potential to be providers of such services.

A questionnaire measuring PHCP perceptions and practices related to counseling on cancer screening and diagnosis was distributed to PHCPs across MoH clinics covering the main regions of Jordan.

A total of 322 practitioners responded (75.1% response). Across most activities involving cancer detection, no more than 30% reported performing activities. Roughly half of PHCPs expressed discomfort at providing cancer-related counseling and at least 43% of non-physicians expressed limited confidence in cancer-related counseling. Confidence was a consistent predictor of provision of counseling and confidence in turn was associated with having greater knowledge, having positive a valuation of counseling, and being a physician. Results reveal points where educational efforts can strengthen PHCPs’ provision of cancer control-related services.

To examine the choices Canadian family medicine residents make for oral anticoagulation (OAC) for patients with nonvalvular atrial fibrillation (AF).

AF increases the risk of strokes. An important consideration in AF management is risk stratification for stroke and prescription of appropriate OAC. Family physicians provide the vast majority of OAC prescriptions.

We administered a survey to residents in multiple Canadian family medicine training programmes. Questions explored the experiences and attitudes towards risk stratification and choices of OAC when presented with standardized clinical scenarios. In each scenario, a novel oral anticoagulant (NOAC) would be the preferred treatment according to the contemporary Canadian and European guidelines.

A total of 247 residents participated in the survey. Most used the congestive heart failure, hypertension, age ≥ 75, diabetes mellitus, stroke or TIA (2 points) (81%) and congestive heart failure, hypertension, age ≥ 75 (2 points) or age 65-74 (1 point), diabetes mellitus, stroke or TIA, vascular disease including peripheral arterial disease, myocardial infarction, or aortic plaque, sex (female) (67%) risk stratification schemes while the preferred bleeding risk stratification scheme was hypertension, abnormal liver or renal function, stroke, bleeding, labile international normalized ratio, elderly (age ≥ 65), drugs or alcohol (84%). In the clinical scenarios, residents generally preferred warfarin in favour of NOACs, independent of training level. Residents ranked the risk of adverse events and the cost to the patient as their most and least important consideration when prescribing OAC, respectively. Therefore in patients with nonvalvular AF, Canadian family medicine residents prefer warfarin in comparison with NOACs despite the latest Canadian and European guideline recommendations. This knowledge gap may be enhanced by multiple factors, including a sometimes magnified fear of adverse events and a rapidly changing landscape in stroke prophylaxis.

To examine assumptions about public–private partnership (PPP) activities and their role in improving public procurement of primary healthcare surgeries.

PPPs were developed to improve the quality of care and patient satisfaction. However, evidence of their effectiveness in delivering health benefits is limited.

A qualitative study design was employed. A total of 25 interviews with public sector staff (n=23) and private sector managers (n=2) were conducted to understand their interpretations of assumptions in the activities of private investors and service contractors participating in Local Improvement Finance Trust (LIFT) partnerships. Realist evaluation principles were applied in the data analysis to interpret the findings.

Six thematic areas of assumed health benefits were identified: (i) quality improvement; (ii) improved risk management; (iii) reduced procurement costs; (iv) increased efficiency; (v) community involvement; and (vi) sustainable investment. Primary Care Trusts that chose to procure their surgeries through LIFT were expected to support its implementation by providing an environment conducive for the private participants to achieve these benefits. Private participant activities were found to be based on a range of explicit and tacit assumptions perceived helpful in achieving government objectives for LIFT.

The success of PPPs depended upon private participants’ (i) capacity to assess how PPP assumptions added value to their activities, (ii) effectiveness in interpreting assumptions in their expected activities, and (iii) preparedness to align their business principles to government objectives for PPPs. They risked missing some of the expected benefits because of some factors constraining realization of the assumptions. The ways in which private participants preferred to carry out their activities also influenced the extent to which expected benefits were achieved. Giving more discretion to public than private participants over critical decisions may help in ensuring that assumptions in PPP activities result in outcomes that match the anticipated health benefits.

Little is known about how interprofessional healthcare providers in nursing homes work together. We know that interprofessional teamwork evolves from trial and error learning and so interprofessional collaboration has to be actively taught. This study aims to gain insights in the perception of professionals towards interprofessional collaboration in nursing homes and the factors that have an impact on interprofessional collaboration.

A qualitative descriptive methodology using focus group interviews and additional semi-structured interviews was performed. In total three focus group sessions with healthcare providers from different disciplines were held and additionally nine semi-structured interviews were executed. A thematic analysis was performed. The transcripts were read to immerse in the data and initial ideas were noted. Both open coding (identification of primary themes) and axial coding (analysis of relationships among themes) were conducted and re-focussed into potential themes.

Four main themes emerge from the analysis: context, collaboration, care and experience. From the findings it seems that healthcare teams in nursing homes work as ‘separated groups’. A lot of collaboration is perceived, but no common vision or responsibility sharing is found. The role description of the different disciplines does not always seem clear or is not always explicit.

In usual care the perceived interactions between professionals are called collaboration. Obviously physicians and all healthcare professionals do not work interprofessionally according to definitions from the literature. This study provided evidence of the awareness that interprofessional collaboration in usual care is situational and fragmentary organised.

This study aimed to explore the ability of sexual health nurses working in the South West of England, to implement new learning within existing sexual health service delivery models. Drawing on Lipsky’s account of street-level bureaucracy to conceptualise policy implementation, the impact of workforce learning on the development of integrated services across this region of the United Kingdom was assessed.

In order to achieve the United Nations’ goal of universal access to sexual health, it is essential for reproductive and sexual health, including HIV provision, to integrate into a single service. This integration requires a commitment to collaboration by service commissioners and an alignment of principles and values across sexual health and contraceptive services. UK health policy has embraced this holistic agenda but moves towards integrating historically separate clinical services, has presented significant workforce development challenges and influenced policy success.

Employing a qualitative approach, the study included data from semi-structured telephone interviews and focus groups, and longitudinal data from pre- and post-intervention surveys, collected between September 2013 and September 2015. Data were collected from 88 nurses undertaking a workforce development programme and six of their service managers. Data were analysed using thematic analysis to identify consistent themes.

Nurses confirmed the role of new learning in enabling them to negotiate the political landscape but expressed frustration at their lack of agency in the integration agenda, exposing a clear dichotomy between the intentions of policy and the reality of practice. Nevertheless, using high levels of professional judgement and discretion practitioners managed the incongruence between policy and practice in order to deliver integrated services in the interests of patients. Workforce education, while essential for the transition to the delivery of integrated services, was insufficient to fulfil the sexual health agenda without a strengthening of public health.

Questionnaires developed for patient evaluation of the quality of primary care are often focussed on primary care systems in developed countries.

To report the development and validation of the patient evaluation scale (PES) designed for use in the Nigerian primary health care context.

An iterative process was used to develop and validate the questionnaire using patients attending 28 primary health centres across eight states in Nigeria. The development involved literature review, patient interviews, expert reviews, cognitive testing with patients and waves of quantitative cross-sectional surveys. The questionnaire’s content validity, internal structures, acceptability, reliability and construct validity are reported.

The full and shortened version of PES with 27 and 18 items, respectively, were developed through these process. The low item non-response from the serial cross-sectional surveys depicts questionnaire’s acceptability among the local population. PES-short form (SF) has Cronbach’s α of 0.87 and three domains (codenamed ‘facility’, ‘organisation’ and ‘health care’) with Cronbach’s αs of 0.78, 0.79 and 0.81, respectively. Items in the multi-dimensional questionnaire demonstrated adequate convergent and discriminant properties. PES-SF scores show significant positive correlation with scores of the full PES and also discriminated population groups in support of a priori hypotheses.

The PES and PES-SF contain items that are relevant to the needs of patients in Nigeria. The good measurement properties of the questionnaire demonstrates its potential usefulness for patient-focussed quality improvement activities in Nigeria. There is still need to translate these questionnaires into major languages in Nigeria and assess their validity against external quality criteria.

Patients living in rural areas often need to travel long distances for access to specialist care. To increase access to specialist care, video consultation between patients in primary healthcare and specialist care has been used. In order for this new method to be developed and used to the fullest, it is important to understand healthcare personnel’s experiences with this intervention.

The aim of this study was to describe healthcare personnel’s experiences using video consultation in their work in primary healthcare.

A mixed methods design was used, and the data were analysed using qualitative and quantitative analysis methods. Interviews were conducted with eight general practitioners and one district nurse, all of whom had conducted a video consultation with a patient and a specialist physician or a cardiac specialist nurse. After each video consultation, the participants completed a consultation report/questionnaire.

Healthcare personnel considered video consultation to provide quicker access to specialist care for the patient, and greater security when the video consultation encounter was conducted at their own primary healthcare centre. They considered video consultation an opportunity to provide education and for the patients to ask questions.

Video consultation is a satisfactory tool for healthcare personnel, and the technology is a new, useful method, especially for the district nurses. Further, video consultation is an opportunity for healthcare personnel to learn. However, for it to work as an accepted method, the technology must function well and be user friendly. It must also be clear that it is beneficial for the patients and the healthcare personnel.

Health care is provided under the conditions in which people live and under the rules and regulations of a prevailing health system. As a consequence, ‘local’ circumstances are an important determinant of the actual care that can be provided and its effects on the health of individuals and populations. This plays in particular, but not exclusively, a role in community-based primary health care. Although this is generally accepted, there is little insight in the impact of the setting and context in which health care is provided on the outcome of care.

This paper argues the case to use this natural variation within and between countries as an opportunity to be used as a form of natural experiment in health research.

We argue that analysing and comparing outcomes across settings, that is comparative outcomes of interventions that have been performed under different health care conditions will improve the understanding of how the real-life setting in which health care is provided – including the health system, the socio-economic circumstances and prevailing cultural values – do determine outcome of care.

To facilitate comparison of research findings across health systems and different socio-economic and cultural contexts, we recommend a more detailed reporting of the conditions and circumstances under which health research has been performed. A set of core variables is proposed for studies in primary health care.

The introduction of the Health and Social Care Bill (2011) changed the role of GPs to include commissioning of health services.

This study aimed to identify any differences in the media portrayal of GPs before and after the introduction of the Bill.

We retrospectively searched four British newspapers over the period 2009–2013 using the media database Nexis. In order to directly compare the findings of the study with the work of Tanner et al., articles relating to GP pay were analysed using thematic analysis. Themes were identified and each article was scored to determine whether it portrayed GPs positively or negatively.

GPs were portrayed slightly less negatively after the introduction of the Bill. The theme of ‘high salaries’ persisted despite reference to ‘pay freezes’. References to decreased trust in the patient–doctor relationship appeared after the introduction of the Bill.

Negative portrayal of GP pay has continued and a lack of trust in GPs has started to be portrayed. This trend may exacerbate the low morale amongst the profession and difficulties in recruiting and retaining GPs.

Spirometry is known to be a gold standard for the diagnosis of chronic obstructive pulmonary disease (COPD). COPD Assessment Test (CAT) is an eight-item questionnaire currently in use to evaluate patients with COPD. In the present study, we aimed to evaluate if CAT is an adequate tool for screening COPD.

In total, 600 persons aging ⩾40 years old were randomly selected from three different family practice units located in the city center. CAT was asked to the participants and a spirometry was used to assess pulmonary obstruction. Pulmonary obstruction was defined as forced expiratory volume in first second/forced vital capacity (FEV1/FVC)<70% and then COPD diagnosis was confirmed with the reversibility test. The relationship between CAT results and pulmonary function test values was evaluated.

In this sampling, the prevalence of COPD was 4.2%. Reliability of the CAT in the study group was acceptable (Cronbach’s α: 0.84). The CAT scores was significantly higher in patients with COPD (P<0.001). There was a significant negative correlation between CAT score and FEV1, FVC and FEV1/FVC ratio (r=−0.31, P<0.001; r=−0.26, P<0.001; r=0.18, P=0.001). Among smokers, phlegm was the predominating symptom (P=0.01). Sensitivity of CAT was 66.67% and its specificity was 75.15% to determine COPD.

CAT is a reliable questionnaire and there is an apparent relationship between the total CAT scores and COPD. However, CAT’s ability to screen COPD is limited since it may miss the symptom-free cases.

This study was to perform unit cost analysis of managing common illnesses comparing between a primary care unit (PCU) and a community pharmacy.

PCU is a key point of access for primary care in Thailand. Although a community pharmacy is an ideal setting, it has not been successfully incorporated in Thailand's health service. Common illnesses are encountered everyday by community pharmacists, an appropriate compensation for this service has not been established.

A primary care service of one educational institution was a study site. Eight common illnesses were emphasised. Patient visits were observed, prospectively at community pharmacy and retrospectively at PCU, during August to October 2013. Labour and material costs related to management of common illnesses were recorded. Total cost divided by total patient visits determined the unit cost. For the community pharmacy, patients were followed up after 3–14 days of visit to evaluate the effectiveness. Sensitivity analysis was performed by varying direct medical cost at ±10–30%.

At the community pharmacy, community pharmacists performed multiple tasks including interviewing and assessing patients, choosing an appropriate treatment and dispensing. Of 9141 visits, 775 (8.5%) with common illnesses were included. Upper respiratory disorder was found the highest 41.9% (325/755). Unit cost of treatment ranged from 54.16 baht (£1.18) for pain to 82.71 baht (£1.80) for skin disorder. Two-thirds of pharmacy visits (77.9%, 539/692) reported complete recovery. Managing common illnesses at the PCU was performed by nurse assistants, nurses, doctors and pharmacists. Of 6701 patient visits to the PCU, 1545 (23.1%) visits were at least one of the eight illnesses. Upper respiratory disorder was the majority, 53.0% (771/1454). Unit cost of treatment ranged from 85.39 baht (£1.86) for eye/ear to 245.93 baht (£5.36) for sexual health. Managing common illness at a community pharmacy shows satisfactory effectiveness with lower unit cost.

To evaluate the variations in effect of public reporting in antibiotic prescribing practice among physicians with different performance in primary healthcare settings.

Overprovision of antibiotics is a major public health concern. Public reporting has been adopted to encourage good antibiotic prescribing practices. However, which group, for instance, high, average or low antibiotic prescribers, accounted for antibiotic prescription reduction has not been fully understood.

A cluster randomized-controlled trial was conducted. In total, 20 primary healthcare institutions in Qianjiang city were paired through a six indicators-synthesized score. Coin flipping was used to assign control–intervention status; 10 were then subjected to intervention where prescription indicators were publicly reported monthly over a one-year period. Prescriptions for upper respiratory tract infections (URTIs) before and after the intervention were collected. Physicians were divided into high, average and low antibiotic prescribers based on their antibiotic prescribing rates last month, which were publicly reported in intervention arm. Multilevel difference-in-differences logit regressions were performed to estimate intervention effect in each physician group on three outcome indicators: prescriptions containing antibiotics, two or more antibiotics and antibiotic injections.

In total, 31 460 URTI prescriptions were collected (16 170 in intervention arm and 15 290 in control arm). Reduction in antibiotic prescription attributed to intervention was 2.82% [95% confidence intervals (CI): −4.09, −1.54%, P<0.001], least significant in low prescribers (−1.41%, 95% CI: −3.81, 0.99%, P=0.249) and most significant in average prescribers (−5.01%, 95% CI: −6.94, −3.07%, P<0.001). Reduction in combined antibiotics prescriptions attributed to intervention was 3.81% (95% CI: −5.23, −2.39%, P<0.001), least significant in low prescribers (−2.42%, 95% CI: −4.39, −0.45%, P=0.016) and most significant in average prescribers (−5.01%, 95% CI: −7.47, −2.56%, P<0.001).

Public reporting can positively influence antibiotic prescribing patterns of physicians for URTIs in primary care settings, with reduction in antibiotic and combined antibiotic prescriptions. The reduction was mainly attributed to average and high antibiotic prescribers.

A comparative analysis of concepts and practices of GP-nurse collaborations in primary health centres in Slovenia and Spain.

Cross-professional collaboration is considered a key element for providing high-quality comprehensive care by combining the expertise of various professions. In many countries, nurses are also being given new and more extensive responsibilities. Implemented concepts of collaborative care need to be analysed within the context of care concepts, organisational structures, and effective collaboration.

Background review of primary care concepts (literature analysis, expert interviews), and evaluation of collaboration in ‘best practice’ health centres in certain regions of Slovenia and Spain. Qualitative content analysis of expert interviews, presentations, observations, and group discussions with professionals and health centre managers.

In Slovenian health centres, the collaboration between GPs and nurses has been strongly shaped by their organisation in separate care units and predominantly case-oriented functions. Conventional power structures between professions hinder effective collaboration. The introduction of a new cross-professional primary care concept has integrated advanced practice nurses into general practice. Conventional hierarchies still exist, but a shared vision of preventive care is gradually strengthening attitudes towards team-oriented care. Formal regulations or incentives for teamwork have yet to be implemented. In Spain, health centres were established along with a team-based care concept that encompasses close physician–nurse collaboration and an autonomous role for nurses in the care process. Nurses collaborate with GPs on more equal terms with conflicts centring on professional disagreements. Team development structures and financial incentives for team achievements have been implemented, encouraging teams to generate their own strategies to improve teamwork.

Clearly defined structures, shared visions of care and team development are important for implementing and maintaining a good collaboration. Central prerequisites are advanced nursing education and greater acceptance of advanced nursing practice.

To investigate general practitioners’ (GPs’) desire and perceived added value of point-of-care (POC) troponin, its effect on referral decisions, and test requirements.

Excluding acute coronary syndrome (ACS) in primary care remains a diagnostic challenges for GPs. Consequently, referral rates of chest pain patients are high, while the incidence of a cardiovascular problem is only 8–15%. Previous studies have shown that GPs are interested in a POC troponin test. This test could enhance rapid exclusion of ACS, thereby preventing unnecessary patient distress, without compromising safety and while reducing costs. However, using this test is not recommended in current guidelines due to uncertainty in the test’s potential added value, and the lower sensitivity early after symptom onset as compared with troponin tests in a regular laboratory.

An online survey containing 34 questions was distributed among 837 Dutch GPs in June 2015.

A total of 126 GPs (15.1%) completed at least 75% of the questions. 67.1% of GPs believe that POC troponin tests have moderate to very high added value. Although the availability of a POC test is expected to increase the frequency at which troponin tests are used, it likely decreases (immediate) referral rates. Of the responding GPs, 78.3% only accept 10 min as the maximum test duration, 78.1% think reimbursement of the POC device is required for implementation, and 68.9% consider it necessary that it can be performed with a finger prick blood sample. In conclusion, according to GPs, the POC troponin test can be of added value to exclude ACS early on. Actual test implementation will depend on test characteristics, including test duration, type of blood sample required, and reimbursement of the analyzer.

This report examined the impact and extent that spatial access to primary care physicians (PCPs) and social neighbourhood-/community-level factors have on diabetes prevalence for Toronto and Chicago.

The two-step floating catchment area method was used to compute spatial access scores. Bivariate correlation and multivariate linear regression identified the factors that were associated with, and/or predicted, diabetes prevalence.

Potential spatial access to PCPs had no strong associations with diabetes prevalence. Low socio-economic status factors and certain ethnic groups were strongly associated with diabetes prevalence for both cities. For Toronto, South American place of birth, households below poverty and high school-level education predicted diabetes prevalence. African ethnicity and households below poverty predicted diabetes prevalence for Chicago.

Although this report found no strong association between diabetes prevalence and access to PCPs, contextual factors significant in past individual-level diabetes studies were associated with diabetes prevalence at the neighbourhood/community level for Toronto and Chicago.

The study purpose was to provide evidence of validity for the Primary Health Care Engagement (PHCE) Scale, based on exploratory factor analysis and reliability findings from a large national survey of regulated nurses residing and working in rural and remote Canadian communities.

There are currently no published provider-level instruments to adequately assess delivery of community-based primary health care, relevant to ongoing primary health care (PHC) reform strategies across Canada and elsewhere. The PHCE Scale reflects a contemporary approach that emphasizes community-oriented and community-based elements of PHC delivery.

Data from the pan-Canadian Nursing Practice in Rural and Remote Canada II (RRNII) survey were used to conduct an exploratory factor analysis and evaluate the internal consistency reliability of the final PHCE Scale.

The RRNII survey sample included 1587 registered nurses, nurse practitioners, licensed practical nurses, and registered psychiatric nurses residing and working in rural and remote Canada. Exploratory factor analysis identified an eight-factor structure across 28 items overall, and good internal consistency reliability was indicated by an α estimate of 0.89 for the final scale. The final 28-item PHCE Scale includes three of four elements in a contemporary approach to PHC (accessibility/availability, community participation, and intersectoral team) and most community-oriented/based elements of PHC (interdisciplinary collaboration, person-centred, continuity, population orientation, and quality improvement). We recommend additional psychometric testing in a range of health care providers and settings, as the PHCE Scale shows promise as a tool for health care planners and researchers to test interventions and track progress in primary health care reform.

The integration of behavioral health services into primary care has led to enhanced use of brief screening measures to identify mental health problems. Although useful, such instruments are largely symptom based and diagnosis specific. This narrow focus can potentially limit the identification of broader social or relational distress in patients that affect medical outcomes, as well as present feasibility challenges using a multi-measure approach in identifying mental health comorbidities.

This exploratory study of adult primary care patients compared an ultra-brief, and widely used measure of global distress across life functioning, the Outcome Rating Scale (ORS), with the Patient Health Questionnaire (PHQ-9 and PHQ-2).

Correlations between the ORS and the PHQ-9 and PHQ-2 indicated agreement between the measures in classifying patients, and the ORS identified significantly more patients in the clinical range.

Although results are preliminary, the ORS may cast a wider net in identifying patients with significant distress in primary care.

To assess and improve the quality of Secondary to Primary Care communication on discharge with a focus on post-surgical wound care.

Hospital discharge summaries are the principle means of relaying accurate information back to primary care healthcare providers regarding a patient’s hospital attendance and any ongoing care that is required. The quality of these summaries can be quiet varied both nationally and local to our Trust. Subsequently the Surgical Directorate were seeing an increased level of additional emergency communication from Primary Care providers especially in relation to post-operative wound care.

A survey was distributed to local Primary Care practitioners to assess satisfaction with the General Surgical Department wound care information located on the discharge summary. Using these results, a wound closure information document was developed and distributed to general practice surgeries, and a patient-held ‘wound care’ card was piloted for two months. The survey was then repeated to determine the success of the intervention.

Post discharge communication was on the whole felt to be of poor quality and lacked a large amount of essential and desirable information. There was a particular absence of relevant information regarding surgical wound closure techniques utilised and their ongoing management. Many Primary Care practitioners acknowledge that their knowledge on this subject can be low. A Trust specific information leaflet combined with a dedicated patient held discharge information card can solve a number of these issues improving Primary and Secondary Care satisfaction and reducing the use of emergency resources and appointments.